Surgery for symptomatic Freiberg's disease: extraarticular dorsal closing-wedge osteotomy in 13 patients followed for 2-4 years

From 1992 through 1995, we have treated 13 patients (10 men) with Freiberg's disease by debridement and dorsal closing-wedge osteotomy of the metatarsal neck. The lesion was located in the second metatarsal head in 10 patients and in the third metatarsal head in 3. After osteotomy, the lesion was away from the joint, so that the smooth and healthy articular cartilage of the metatarsal head faced the phalangeal cartilage. The average follow-up period was 40 (28-54) months. The subjective outcome was good or excellent in 11 patients, fair in 1, and poor in 1. We found MRI useful in determining the extent of the lesion when planning correction.     

Dynamics of hip joint remodeling after Chiari osteotomy: 10 patients with neuromuscular disease followed for 8 years

We analyzed the development of 10 hips in 10 consecutive patients with neuromuscular disease (9 with spasticity, 1 with Charcot-Marie-Tooth disease) who had undergone Chiari osteotomy for painful hip subluxation or dislocation. The patients were 11 (5-19) years old at surgery and follow-up time was 8 (6-11) years.

The Chiari osteotomy particularly improved and maintained femoral head coverage. These parameters did not show the postoperative deterioration noted in some other studies. The osteotomy did not improve femoral head lateral displacement. Throughout the postoperative period, the configuration of the proximal femur and the height of the joint cartilage were unchanged and undisturbed, indicating that osteotomy did not place excessive or uneven pressure on the femoral head.

The ambulatory status of the patients was dependent on the severity of the underlying disease, and was not improved by osteotomy. However, pain associated with subluxation or dislocation was reduced in 9 of the patients.     

Effect of minimally invasive distal first metatarsal osteotomy on blood flow of the metatarsal head

BackgroundDistal first metatarsal osteotomy is an option for operative treatment of mild to severe hallux valgus (HV) deformities. Minimally invasive distal linear metatarsal osteotomy (DLMO) provides good outcomes without avascular necrosis (AVN) of the metatarsal head. However, no reports have described the in vivo blood flow changes in the metatarsal head after osteotomy. This study was performed to evaluate the in vivo blood flow of the pre- and post-osteotomy metatarsal head in patients with HV using laser Doppler flowmetry and thus clarify the effect of minimally invasive distal first metatarsal osteotomy on the change in blood flow.MethodsFrom April 2015 to October 2016, DLMO was performed on 13 feet with HV in 10 patients (2 men, 8 women). Blood flow measurements of the pre- and post-osteotomy first metatarsal head in all feet were performed by laser Doppler flowmetry. AVN was evaluated using plain radiographs at the final postoperative follow-up.ResultsThe median pre- and post-osteotomy blood flow was 1.5 (0.97–1.95) and 1.46 (0.98–1.77) ml/min/100 g, respectively (median change in blood flow, 0.00; 95% CI, ?0.23–0.13; P = 0.72). The rate of change in the blood flow was 0.0% (95% CI, ?11.9%–8.7%; range, ?28.6%–64.7%), and only three patients (23.1%) showed a decrease of ≥10%. The median pre- and post-osteotomy systolic blood pressure was 90 (84.5–97) and 93 (84.5–95) mmHg, respectively (median change in blood pressure, 0.00; 95% CI, ?3.0–2.0; P = 0.82). The rate of change in the systolic blood pressure was 0.0% (95% CI, ?3.1%–2.2%; range, ?9.1%–24.0%). No radiographic evidence of AVN was present at the final follow-up.ConclusionsNo significant difference was found in the rate of change in blood flow pre- and post-osteotomy, suggesting that minimally invasive distal first metatarsal osteotomy does not influence blood flow of the metatarsal head.     

Rheumatoid Forefoot Reconstruction in Nonrheumatic Patients: Lesser Metatarsal Head Resection versus Osteotomy

In the literature, first metatarsophalangeal joint arthrodesis with lesser metatarsal head resection seems to be a reliable procedure in rheumatoid foot deformity. Maybe this procedure could be proposed in nonrheumatoid severe forefoot deformity (hallux valgus angle >40° and lesser metatarsophalangeal dislocation). The aim of this study was to compare radiological and clinical outcomes between lesser metatarsal head resection and lesser metatarsal head osteotomy in nonrheumatoid patients. Thirty-nine patients (56 feet) suffering from well-defined nonrheumatoid severe forefoot deformity were retrospectively enrolled in our institution between 2009 and 2015. Metatarsal head resection and metatarsal head osteotomy represented 13 patients (20 feet) and 26 patients (36 feet), respectively. In this observational study, a rheumatoid population (21 patients) was included as the control. The clinical outcome measures consisted of American Orthopaedic Foot and Ankle Society score, Foot and Ankle Ability Measurement, and Short Form-36. The radiological outcomes were: intermetatarsal angle, hallux valgus angle, and metatarsophalangeal alignment. Mean follow-up was 24 months. Satisfaction rate was, respectively, 92% for resection, 91% for osteotomy procedure, and 80% for surgery in rheumatoid patients. Short Form-36 global score was, respectively, 80.7 (52.5-96.4), 76 (57.7-93), and 68.3 (22.6-86). No functional outcome difference was found between resection and osteotomy procedures, except that the metatarsal head resection group had poorer results in sports activities than the osteotomy group. Complications were similar between osteotomy and resection (p > .05). The radiological outcomes were improved significantly from preoperative to postoperative. First metatarsophalangeal joint arthrodesis with lesser metatarsal head resection in nonrheumatoid severe forefoot deformity might be a good therapeutic option.     

Components of the Wilson Osteotomy That Are Effective on Hallux Valgus Repair

Wilson osteotomy of the first metatarsal is a technically simple and reliable operation for the correction of the hallux valgus (HV) deformity. The major anatomic components of the osteotomy are the osteotomy angle and the distance of the osteotomy to the first metatarsophalangeal (MTP) joint. Lateralization of the first metatarsal head is the rationale for correction of the deformity. The main disadvantage of the technique is the considerable shortening of the first metatarsal. The relation between the amount of HV correction, first metatarsal shortening, and the anatomic parameters of the osteotomy was evaluated. Radiographs of 46 feet of 32 patients were retrospectively evaluated after an average follow-up period of 31.4 months. From the preoperative, early postoperative, and last control radiographs, the amount of HV correction, first metatarsal shortening, the osteotomy angle, the distance of the osteotomy to the first MTP joint, and lateralization of the first metatarsal head were measured. The presented study indicated that the osteotomy angle and the lateral displacement of the metatarsal head have a significant correlation with the amount of HV correction. Distance of the osteotomy to the first MTP joint has no relevance with the repair of the deformity. A positive linear correlation was present between the osteotomy angle and the first metatarsal shortening. Because the amount of first metatarsal shortening has significant influence over the clinical result, the main aim in a Wilson osteotomy should be maximum lateral displacement of the metatarsal head with a minimum osteotomy angle.     

Shortening Proximal Chevron Metatarsal Osteotomy for Patients With a Hallux Valgus Deformity With Advanced Arthritis

To correct hallux valgus deformities in patients with advanced arthritis of the first metatarsophalangeal joint, we designed a new reverse chevron-type shortening osteotomy technique that could be used to correct valgus deformities at the proximal metatarsal level, as well as shorten and lower the metatarsal, in a 1-time procedure. Sixteen feet in 16 patients with a minimum of 18 months follow-up who underwent a shortening proximal chevron metatarsal osteotomy for a hallux valgus deformity with advanced arthritic change between January 2014 and March 2016 were reviewed in this study. Double chevron osteotomies with 20° of plantar-ward obliquity at the proximal metatarsal level were made at 5-mm intervals for simultaneous valgus correction and metatarsal shortening. An additional Weil osteotomy of the second metatarsal was performed in all feet. Patients’ mean age was 57.88 ± 6.55 years. The deformity was satisfactorily corrected by the operation. The first metatarsal was shortened by approximately 8.75 mm, and the relative length of the second metatarsal did not differ significantly postoperatively (p?=?.179). The relative second metatarsal height, as seen on forefoot axial radiographs, was maintained constantly, with no significant difference (p?=?.215). No painful plantar callosity or transfer metatarsalgia under the second metatarsal head was observed postoperatively. A shortening proximal chevron metatarsal osteotomy for hallux valgus deformities with advanced arthritic change showed a good result with respect to deformity correction and pain relief. Appropriate lowering and an additional Weil osteotomy effectively prevented postoperative pain and painful callosity under the second metatarsal head.     

The Mitchell bunionectomy: a prospective study of 60 consecutive cases utilizing single K-wire fixation.

The authors prospectively evaluated 45 patients (60 feet) affected by hallux valgus and treated with a distal metatarsal osteotomy. The surgical procedure consisted of a modified Mitchell osteotomy, in which fixation was achieved with a Kirschner wire that was driven into the proximal osteotomy fragment and buttressed the distal one. Early weightbearing was allowed without a cast. Follow-up averaged 25 months. The mean American Orthopedic Foot and Ankle Society clinical hallux score increased from 44.6/100 preoperatively to 83.2/100. Radiographic evaluation showed that mean metatarsophalangeal and intermetatarsal angles decreased respectively from 31.7 degrees to 16.9 degrees, and from 15.4 degrees to 8.6 degrees. Short-term loss of correction occurred in three cases (4%). Six feet (10%) had unrelieved metatarsalgia that was related to excessive shortening of the first metatarsal and/or inappropriate orientation of the metatarsal head. Stabilization of the Mitchell osteotomy with a Kirschner wire proved safe and effective for the surgical correction of mild to moderate hallux valgus.     

Stability of a cannulated screw versus a Kirschner wire for the proximal crescentic osteotomy of the first metatarsal: a biomechanical study.

The purpose of this study was to compare the stability of a Kirschner wire (K-wire) versus a single cannulated screw for fixation of the proximal crescentic first metatarsal osteotomy. Seven matched pairs of fresh-frozen human cadaver first metatarsal specimens were dissected out en bloc at the first metatarsal-medial cuneiform complex; right and left specimens were randomized as to fixation. In screw specimens, a cannulated screw was mounted from the proximal medial side of the metatarsal, traversing osteotomy and engaging the lateral diaphyseal cortical bone. In the corresponding specimen, a K-wire was placed from the distal medial metatarsal cortex oriented as close to the longitudinal metatarsal axis as possible. Using a materials testing machine, a continuous load was applied to the plantar aspect of the metatarsal head at a rate of 5 mm/min until a displacement of 10 mm was reached. The following parameters were measured: initial stiffness of the entire specimen, stiffness of the osteotomy, the force required to create a 1-mm displacement, the force required to create a 0.15-mm gap across the osteotomy, and the ultimate force to create the 10-mm displacement. Both specimen and osteotomy stiffness were found to be significantly higher for screw fixation versus the K-wire (P <.05). Although there was also a difference in the force-to-failure load in favor of screw fixation, this result was found not found to be statistically significant.     

Radiographic results after percutaneous distal metatarsal osteotomy for correction of hallux valgus deformity

BACKGROUND: The goal of the study was to evaluate the short-term radiographic results and complications of a percutaneous distal metatarsal osteotomy for hallux valgus. METHODS: From June, 2005, until October, 2005, a percutaneous distal first metatarsal osteotomy was performed in 13 consecutive patients. All patients had mild to moderate hallux valgus deformities preoperatively. The mean postoperative followup was 130 (range 50 to 207) days. The radiographs were reviewed for hallux valgus angle, 1-2 intermetatarsal angle, nonunion, malunion, and osteonecrosis. RESULTS: The mean 2 weeks postoperative hallux valgus angle demonstrated a statistically significant (p < 0.0001) improvement from 25 (16 to 33) degrees preoperatively to 5 (-1 to 12) degrees postoperatively. Nine patients (69%) demonstrated dorsally angulated alignment of the first metatarsal at the first postoperative examination averaging 10.8 (6 to 15) degrees that increased to 15.9 (10 to 22) degrees at final followup. One patient developed cystic changes within the metatarsal head consistent with osteonecrosis. One patient developed a nonunion with no evidence of radiographic healing at most recent followup of 180 days. Five patients (38%) had recurrent hallux valgus defined as a final angle of greater than 15 degrees. CONCLUSIONS: Percutaneous distal metatarsal osteotomy for hallux valgus is associated with an unacceptable rate of complications, specifically, osteonecrosis, nonunion, malunion, and recurrence. The intraoperative correction was routinely lost after removal of the intramedullary Kirschner wire, leading to a high rate of recurrence of hallux valgus deformity as well as dorsal elevation of the capital fragment.     

Fixation of Hohmann's osteotomy for hallux valgus

We modified Hohmann's (1923) osteotomy for hallux valgus by internal fixation of the metatarsal head with no need for a plaster cast. Five (2-10) years post-operatively, all 20 patients (32 feet) had complete relief and all but one was satisfied with the cosmetic result. However, we now routinely add osteotomies of the second and third metatarsal neck to prevent, albeit asymptomatic, callosities.     

Minimally invasive hallux valgus correction with Internal Hallux Fixator® — A comparative cadaver study

BackgroundThe Internal Hallux Fixator® (IHF®; Waldemar Link, Hamburg, Germany) was designed for open surgical hallux valgus correction. It allows a defined lateralisation of the first metatarsal head after V-shaped, Chevron-like distal metatarsal osteotomy in order to correct mild to middle hallux valgus deformities. The intramedullary fixation provides dynamic compression of the osteotomy and thus postoperative full weight bearing mobilization is an integral part of the therapy.This comparative cadaver model study investigates the feasibility of implanting the device using a minimally invasive technique and compares its capability of first metatarsal head lateralisation to the established 3rd generation MICA (Minimally Invasive Chevron and Akin osteotomy) technique.Methods16 fresh frozen cadaveric feet (8 left, 8 right) of 8 body donors received either MICA (Group 1), or an IHF® in a minimally invasive technique (Group 2). The achievable first metatarsal head lateralisation and operating time were measured and pitfalls recorded.ResultsThis cadaver model study confirmed, the minimally invasive implantation of the Internal Hallux Fixator® can be performed reliably via 10 mm mini incision with V-shaped distal metatarsal osteotomy. The mean first metatarsal head lateralisation was comparable between the groups with no statistically significant difference (7.2 (±1.9) mm in G1, or 8.3 (±0.8) mm in G2; p = 0.09).The IHF® was inserted and fixed in mean 3.7 (±0.6) min, whereas double screw fixation needed 10 (±3.7) min.Level of Clinical Evidence5, Cadaver model study.     

Hohmann-Thomasen metatarsal osteotomy for tailor's bunion (bunionette)

We used subcapital displacement osteotomy of the fifth metatarsal bone and peg-and-hole fixation to treat a tailor's bunion (bunionette) in forty-four feet (twenty-seven patients). The result was good in 86 per cent, fair in 9 per cent, and poor in 5 per cent. All but one of the patients were satisfied with the result. The average medial displacement of the head of the fifth metatarsal was five millimeters. In all feet, secure union was noted in five weeks, and no patient had osteonecrosis of the head of the fifth metatarsal.     

Modifications of the Weil osteotomy have no effect on plantar pressure

Previous studies have shown that increasing angulation of the Weil osteotomy produces greater plantar translation of the metatarsal head. Modifications have been proposed to reduce plantar translation. However, there is no evidence that the increased plantar translation with a Weil osteotomy is clinically significant or that these modifications are required. Ten lower extremities consisting of five matched pairs were used to evaluate whether different configurations of the Weil osteotomy altered plantar pressure in a dynamic cadaver model. For each pair, an oblique Weil osteotomy with a 5-mm shift was done on one side and a standard (parallel) Weil osteotomy with a 5-mm shift was done on the matched foot. A 4-mm slice resection and a metatarsal head resection then were done sequentially. Plantar pressures were measured with cyclic loading to 700 N at a frequency of 1 Hz with an F-scan in-shoe sensor on the intact specimens and after each intervention. Increased plantar translation of the metatarsal head with a more oblique Weil osteotomy did not significantly increase plantar pressure, and the 4-mm slice resection did not significantly unload the metatarsal head. Only complete metatarsal head resection significantly unloaded the metatarsal head.     

Reverse Austin osteotomy for correction of hallux varus

A case of hallux varus and extensus of unusual etiology and treatment is presented. Special emphasis is directed toward the angle formed between the first metatarsal base and medial cuneiform, which these investigators believe has not been previously described. The procedure performed is a reverse Austin bunionectomy with a step-by-step outline of soft tissue procedures attempted before osteotomy. The cartilage at the first metatarsal head was medially adapted and of normal structure and function preoperatively; therefore, the decision was made to perform a joint preservation procedure.     

Lateral shifting of the first metatarsal head in hallux valgus surgery: effect on sesamoid reduction

Thirty feet with hallux valgus (HV) having grade 2 and 3 sesamoid stations on AP radiographs were examined after Lindgren-Turan oblique distal metatarsal osteotomy with a minimum follow-up of 12 months. Adductor tendon release from the lateral sesamoid was not performed to determine the isolated effect of distal metatarsal osteotomy on metatarsosesamoidal reduction. Of the 30 feet, 20 (67%) had reduced and 10 (33%) unreduced sesamoids at the follow-up. Ultimately, distal metatarsal osteotomy (DMO) with lateral shifting of the first metatarsal head more than 7.2 mm was found to reduce the sesamoids in the great majority of the cases (95% CI 7.243-9.757). Sesamoid release is redundant for metatarsosesamoidal reduction if sufficient lateral shift of the first metatarsal head over the sesamoids is accomplished.     

Fixation of Hohmann's osteotomy for hallux valgus

We modified Hohmann's (1923) osteotomy for hallux valgus by internal fixation of the metatarsal head with no need for a plaster cast. Five (2–10) years post-operatively, all 20 patients (32 feet) had complete relief and all but one was satisfied with the cosmetic result. However, we now routinely add osteotomies of the second and third metatarsal neck to prevent, albeit asymptomatic, callosities.     

Ultrasound-guided distal minimally invasive metatarsal osteotomies (US-DMMO): A cadaveric study about its safety and accuracy

BackgroundDistal minimally invasive metatarsal osteotomies have become increasingly popular. This technique requires fluoroscopic control, but recently, an ultrasound-guided procedure has been described. The aim of this anatomical study was to assess the quality safety of ultrasound-guided minimally invasive metatarsal osteotomies.MethodsUltrasound-guided distal minimally invasive metatarsal osteotomies were performed in 9 cadaveric pieces. The location of the osteotomy, its angulation, and the adjacent anatomical structures injuries was evaluatedResultsThirty-six osteotomies were performed. The osteotomy was metaphyseal in 97.2% of the cases, the average angulation was 47.67° (±4.49, 40?59°) and the average distance to the articular cartilage was 3.22 mm (±1.27, 1?7 mm). One osteotomy (2.8%) was intraarticular and there was one joint capsule lesion (2.8%). The failure, the extreme point distance and angulation values, and the joint capsule injury correspond to a fifth metatarsal.ConclusionsThe ultrasound-guided technique is safe and allows a correct location and angulation of the osteotomies.     

Shortening and vertical shift at osteotomy of 1st metatarsal for hallux valgus—the effect on forefoot loading

The effects of weight distribution of the foot were observed in 81 patients undergoing 137 modified Mitchell's osteotomies for hallux valgus deformities. Footprints, using the Harris Beath mat, were done and X-rays measured before and after surgery. Shortening of the 1st metatarsal at surgery of more than 5 mm and upwards tilt of the head of more than 2 mm both increase the risk of transfer of weight distribution from the 1st metatarsal head to the lesser metatarsal heads.When shortening was combined with upwards tilt at osteotomy, weight transfer to the lesser metatarsal heads became almost universal. When shortening was combined with downwards tilt at osteotomy, this load transfer was much less frequent.     

The tailor's bunionette deformity: a field guide to surgical correction

The author presents a detailed review of the Tailor's bunionette deformity of the fifth metatarsal with special emphasis on radiographic analysis and surgical correction. The surgical techniques discussed include (1) partial metatarsal head ostectomy; (2) metatarsal head resection; (3) minimal incision osteotomy; (4) osteotomies about the metatarsal head-neck, shaft, and base; and (5) ancillary soft tissue procedures. Techniques employed to prevent and correct potential complications are discussed in detail for each osteotomy.     

Weil截骨术与Jacopy截骨术治疗应力性跖痛症的临床疗效对比观察

背景：跖痛症是指发生于跖骨头下方的前足疼痛,可由解剖结构异常、病理性或医源性因素诱发。其病变主要是因为前足集中的局部应力负荷反复作用造成。治疗可分为保守治疗与手术治疗,对大部分跖痛症而言,采用保守治疗即可取得较好的疗效,若保守治疗无效,则可采取手术治疗,其目的是恢复前足正常的应力分布。目的：探讨跖骨远端weil截骨术与Jacoby截骨术治疗应力性跖痛症的临床疗效,从而为临床上更加合理有效的治疗跖痛症提供方法和依据。方法：2010年5月至2012年9月,我院收治应力性跖痛症患者65例,其中42例（63足）患者资料完整,得到随访,男8例（13足）,女34例（50足）;年龄39～78岁,平均56-3岁。单侧11例,双侧31例;病变于第2跖骨头下24例,第3跖骨头下ll例,第2、3跖骨头下同时累及7例。合并跖趾关节脱位12例,跽外翻畸形16例,跖间神经瘤5例。所有病例随机分为A、B两组,A组19例（32足）,B组23例（31足）。A组采用跖骨远端Weil截骨术、B组采用Jacoby截骨术治疗,经过平均18个月的随访,对手术前后局部疼痛症状、患者足底应力变化、足部功能改善情况进行比较分析。结果：两种手术前后疼痛缓解均有显著性差异,以Weil截骨组疼痛缓解更明显,但两组间疼痛缓解无明显统计学差异。两组患者手术前后患趾跖骨头下应力峰值明显下降。Weil截骨组,手术前后立位时和足跟抬高时的病变跖骨头下应力分别下降35％和51％;Jacoby截骨组分别下降25％,n45％。根据美国足踝外科协会Maryland跖趾关节百分评分法对两组患者进行评定：优,A组24足（占75％）,B组22足（占71％）;良,A组6足（占18．8％）,B组5足（占16．1％）;可,A组2足（占6．2％）,B组4足（占12．9％）。A组优良率为93．8％,B组为87．1％。结论：对于应力性跖痛症患者,跖骨远端Weil截骨术与Jacoby截骨术治疗均可取得满意确切的效果。但weil截骨术手术操作技巧要求更高,Jacoby截骨术对初学者更易掌握。临床需要根据患者的实际情况及个体需求灵活选择。